Tender plaques of the trunk

Presenter: Jonathan Cleaver DO, Cathy Koger DO, Peter Knabel DO, Stephen Plumb DO

Dermatology Program: Northeast Regional Medical Center

Program Director: Dr. Lloyd Cleaver

Submitted on: June 2, 2012

CHIEF COMPLAINT: Tender and irritated plaque that drains

CLINICAL HISTORY: A 37-year-old Caucasian male presented with a 1-year history of a tender and irritated plaque that would drain fluid located on the left anterior shoulder that drains clear fluid. No previous therapy.

PHYSICAL EXAM:
On physical examination, a well-circumscribed 1.4cm x 2.5cm tender, red to yellow plaque with telangiectasia was noted on the left anterior shoulder. On further examination, a 2.4cm x 3.0cm indurated, erythematous, subcutaneous plaque was noted on the right lower back.

LABORATORY TESTS:

A CBC, CMP, and a serum protein electrophoresis revealed a WBC of 12.9 K/cmm, blood glucose of 277 mg/dl, HgA1c of 10.8%, and the serum proteins were within normal range. The patient was referred to hematology and oncology where they recommended a CT scan of the chest, abdomen, pelvis, a serum immunoelectrophoresis, Beta 2 microglobulin, quantitative IgG, IgA, IgM, a 24hr urine for urine protein electrophoresis and urine immunoelectrophoresis. All these tests were within normal limits.

DERMATOHISTOPATHOLOGY:

Histologically the sections demonstrated a relatively unremarkable epidermis. The dermis showed numerous necrobiotic foci surrounded by lymphocytes and histiocytes. Multiple xanthomatous cell and areas of cholesterol clefts were appreciated